DEPARTMENT OF POST GRADUATE STUDIES IN                   SWASTHAVRITTA              SHRI DHARMASTHALA MANJUNATHESHWARA    ...
CONTENTSI.       Introduction                                 1-4II.      Literary review      1. Sthoulya                ...
3. Udvartana         h. Paribhasha                               60         i. Concept of Rookshana                     61...
Acknowledgement                             Acknowledgement       I offer my prayers to Lord Aanjaneya and Sri Raghavendra...
Acknowledgement        I am thankful to internees Raghavendra, Poornima, Sudarani,Shivananda, Nalina and Usha who helped m...
List of TablesTable   Content                                                     Page no.no.1       Paryaya of Sthoulya  ...
Cont…Table no.   Content                                           Page no.44          Sthoulya cases- Body frame         ...
Contd..Table     Content                                               Page no.no.84        Age wise distribution of surve...
Abbreviations                       Abbreviations(1) Cha. sam             -       Charaka samhita(2) Su. sam              ...
Introduction       Scientific and technological progress has made man highly sensitive andcritical; there by giving rise t...
Introductionone’s own physique in moderation. In Dasha vidha pareeksha, samhananapareeksha is to be examined to determine ...
Introductionwhich requires medical supervision. On contrary, Udvarthana is a procedurewhich can be undertaken daily with a...
Introduction Clinical study       This part of the study deals with the materials and methods. The methodsinclude the stud...
Review of literature-Sthoulya                           Sthoulya Paribhasha      The word “Sthoola” is derived from root “...
Review of literature-Sthoulya                                Sthoulya Nirukthi         Different scholars had given their ...
Review of literature-Sthoulya                               Historical backgroundI) Reference in Vedas:          Ayurveda ...
Review of literature-Sthoulya b. Laghutrayi 1. Madhava Nidana:       He is the first author to describe this disease under...
Review of literature-Sthoulya4. Chakradatta:     Acharya Chakrapani datta has explained treatment of Sthoulya in 36thchapt...
Review of literature-Sthoulya                Physiological consideration of Meda Dhatu:Utpathi:       When the sukshma bha...
Review of literature-SthoulyaMeda Dhatu Pramana:      Two anjali is said to be the quantity of Meda dhatu.Meda sara purush...
Review of literature-Sthoulya                                Sthoulya Nidana       Nidana is an important factor for manif...
Review of literature-Sthoulya       Aharaja nidana are wide spectrum of etiological factors, which is havingvariation in A...
Review of literature-SthoulyaMadhura Rasapradana ahara:      This Madhura Rasa is having the Kapha prakopaka property beca...
Review of literature-SthoulyaTable no.04 showing viharatmaka Nidana of Sthoulya:Sl no    Nidana                   Ch.     ...
Review of literature-SthoulyaTable no.07 showing important Nidana of Sthoulya with its features:Sl.   Nidana              ...
Review of literature-Sthoulya                              Sthoulya Samprapti         It is defined as “the description of...
Review of literature-Sthoulya                                    Samprapthi chakra        Nidana sevana    Ahara, Vihara, ...
Review of literature-Sthoulya                          Samprapthi Ghataka Dosha:    Kapha          –      Kledaka    Vata...
Review of literature-SthoulyaBrief description about important Lakshana:   1. Meda- Mamsa Vrudhi:             As it is a M...
Review of literature-Sthoulya5. Krucchra vyavaya:          Shukra dhatu is responsible for vyavaya. When its rate of   for...
Review of literature-Sthoulya                                      Poorvaroopa       It refers to the features, which indi...
Review of literature-Sthoulya                                            Rupa           When the Vyadhi kriya kala is in f...
Review of literature-Sthoulya             The lakshana of Sthoulya had been described under different headings     like:1....
Review of literature-SthoulyaTable no.08 Showing Sthoulya lakshana given by different authors:Sl.   Lakshana             C...
Review of literature-Sthoulya                                    Upadrava       This manifests in last kriya kala. The con...
Review of literature-Sthoulyaupadrava. Bhava mishra and Yogaratnakara have used the word “Sudustara” inthe place of upadra...
Review of literature-Sthoulya                                 Sadhyasadhyata       Ancient scholars keeping in view of suc...
Review of literature-Sthoulya                               Sthoulya Chikitsa     The process by which dhatu samyatha is a...
Review of literature-SthoulyaSatatakarshana Chikitsa:     For the Sthoola rogi, karshana should be done continuously. Beca...
Review of literature-Sthoulyaa. Vamana:       This is the procedure done to expel out the utklista Kapha from the body.Thi...
Review of literature-Sthoulya                                    Pathyapathya       This is the unique contribution of Ayu...
Review of literature-SthoulyaTable no.11 showing Vihararupi Pathya - Apathya for Sthoulya:            Pathya              ...
Review of literature-Obesity                                       Lipids       The term “lipids” is applied to a group of...
Review of literature-Obesitysmall part remains as diglycerides. The action of Enteric Lipase, present in smallintestine mu...
Review of literature-Obesity“Lipoprotein”. These are spherical particles that contain hundreds of molecule.In a lipoprotei...
Review of literature-Obesitydepositing some of their Triglycerides in adipose cells VLDL are converted toLDL      Low-den...
Review of literature-Obesity        Food products like eggs, milk products, meat, beef, and pork. Etc. are therich source ...
Review of literature-ObesityThe following table no.13 shows the normal limits of blood cholesterol.Sl.No.       Blood Chol...
Review of literature-ObesityThe following table (no.14) shows the distribution of adipose tissue.SL.NO      STORAGE SITE O...
Review of literature-Obesity       The glycerol and fatty acids that result from Liposis are catabolised viadifferent path...
Review of literature-Obesity                                    Etymology       The word Obesity is derived from Latin ter...
Review of literature-Obesity          Synonyms of obesity                       Synonyms of obese           Plumpness    ...
Review of literature-Obesity                               AETIO-PATHOGENSIS      The causes of obesity can be studied und...
Review of literature-Obesity        It has been shown that obese patient eat more than they admit to eating, and     over ...
Review of literature-Obesity☻ Genetic factors:              It is very difficult to assess the role of genes in the manife...
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EFFECT OF UDVARTHANA IN STHOULYA” ‘PRASANNA KUMAR K’ DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITHA S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL,HASSAN

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  1. 1. DEPARTMENT OF POST GRADUATE STUDIES IN SWASTHAVRITTA SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF AYURVEDA & HOSPITAL HASSAN - 573 201. Certificate This is to certify that the thesis entitled “EFFECT OFUDVARTHANA IN STHOULYA” is the record of research workconducted by ‘PRASANNA KUMAR K’ under my direct supervision andguidance as a partial fulfillment for the award of the degree of M.D.(Ayu)in Swasthavritta. Some of the observations made in this elaborative clinicalstudy are original and have definitely contributed in the advancement of theexisting knowledge of the subject. The candidate has fulfilled all the requirement of ordinanceslaid down in the prospectus of Rajiv Gandhi University of Health Sciences,Bangalore, Karnataka for the award of Degree of Doctor of Medicine(Ayu.) Swasthavritta. I am fully satisfied with his work and recommend this thesis tobe submitted for adjudication.Guide HODDr. Sajitha.K M.D.(Ay) Prof. Ramana. G.V M.D (Ay).Asst. Prof. Prof. & HODDept. of PG studies in Swasthavritta Dept. of PG studies in SwasthavrittaSDM College of Ayurveda & Hospital SDM College of Ayurveda & HospitalHASSAN. HASSAN.Date: 28-03-04Place: HASSAN
  2. 2. CONTENTSI. Introduction 1-4II. Literary review 1. Sthoulya 5-32 a. Paribhasha 6 b. Historical Background 7-9 c. Physiological consideration of Meda Dhatu 10-11 d. Nidana 12-16 e. Samprapthi 17-21 f. Poorvaroopa 22 g. Roopa 23-25 h. Upadrava 26-27 i. Sadhyasadhyata 28 j. Chikitsa 29-33 2. Obesity a. Lipids 34-41 b. Definition 42-43 c. Etio-Pathogenesis 44-50 d. Assessment 51-54 e. Morbidity- Mortality 55 f. Complication 55 g. Treatment 56-59
  3. 3. 3. Udvartana h. Paribhasha 60 i. Concept of Rookshana 61-63 j. Historical Background 64 k. Classification 65 l. Benefits 66 m. Procedure and mode of Action (rubbing) 67-70 III. Clinical study a. Study design 71 b. Reason for selecting Study Design 72 c. Objectives of Study 74 d. Selection criteria 74 e. Objective Parameters 75 f. Subjective Parameters 75-78 g. Drug Review 79-80 i. Treatment Procedure 81-82 IV. Observation and Results 83-109 V. Discussion 110-124 VI. Summary and Conclusion 125-129 VII. List of Reference 130-131 VIII. Bibliography 132-133 IX. Annexure I-XIV
  4. 4. Acknowledgement Acknowledgement I offer my prayers to Lord Aanjaneya and Sri Raghavendra Swamijiwho gave me strength to overcome all the difficulties during this Thesis work. I bow my head on the foot of Dr. Virendra Hegdeji, the founderpresident of SDMCA, Hassan for his endless service to society. I am very much thankful to Prof. Prasanna .N. Rao, Principal, whoprovided the necessary facilities for the completion of this work. I express my sincere gratitude to most honourable and esteemed teachersDr. Ramana.G.V, HOD and Dr. Sajitha .K, Guide, for their unforgettableparental affection and patience cooperation to give suggestions at every step inaccomplishing the present work. My most respects and indebtedness to Dr. Sekhar, Dr. Bhaskar Rao,Dr. Mallika, Dr. Muralidhar Pujar, Dr. Prasanna Kerur, Dr. Sanjay Dasand Statistician Dr. Mahadevappa for their valuable suggestions. I take this opportunity to thank Prof. B.G. Gopinath, Dr. B. SrinivasPrasad, Dr.Chandrashekar, Dr. Prakash Mangalasseri Dr. kishorePatwardan and Dr. Kiran Gowda who taught me the science and arts ofmedicine. My vocabulary falls short of suitable words to express my deep sense ofgratitude to my friends Dr. Sairam, Dr. Krishna, Dr. Sudheer and Dr. Suhasfor their timely support and brotherly care. I am greatfull to Dr. Manjunath N.S, Dr. Guruprasad. K andDr.Vijaya Lakshmi for their constant help. It is a privilege for me to express my thanks to Dr.Srinibash Sahoo,Dr.AshwinKumar, Dr.Raju, Dr.Prasanna Aithal, Dr.Ashwini MJ,Dr.Gururaj, Dr.Srinivas GK, Dr.Amit Deshmukh, Dr.Vijay Biradar,Dr.Gopikrishna, Dr.Dheeraj, , Dr.VishalAgarwal, and Dr.Manjunath NP. I express my best wishes to Dr. Sudheendra, Dr. Shivakumar,Dr.Guhesh, Dr. Monilal, Dr. Srikanth, Dr. Adithi, Dr. Manish and Dr.Uday. Effect of Udvarthana in Sthoulya
  5. 5. Acknowledgement I am thankful to internees Raghavendra, Poornima, Sudarani,Shivananda, Nalina and Usha who helped me for survey work. It was not possible to complete this work without Patients therefore I amvery much greatfull to each and every patient who cooperated me for this work. I fail in my duty if I don’t recall Dr. Srikanth PL, Dr. Madhav Diggavi,Dr. Srinivas T, Dr. Vishala, Dr. Anupama, Dr. Gurubasavaraj and Shobhafor their inspiration to join MD. I take this opportunity to thank whole heartedly to Mr.Raghavendrachar.B and Mr.Ramachandra who helped me for getting MDseat. This work has not been completed if Mr. Venugopal K andMr.Venugopalachar had not supported and blessed me. I am greatfull to Smt.Shantha bai- my grand maa, Smt.Shashikala, Sri.Muralidhar Rao,Smt.Chayya Kulkarni, Smt.Sudha shyati and Sri Eranna Pathrimath fortheir encouragement and blessings. This world of words failed to provide me a word just capable ofexpressing my feelings to my friend late Preethi for her long-lasting inspiration. I heartly acknowledge my love and affection to my brother Praveen,sisters Poornima and Pallavi, Mr. Satish and my sweet Shreya. On this occasion with a great reverence I humbly offer my pranamas atthe lotus feet of my mother Smt. Rekha Kulkarni and father Sri. K. SatyaPrakash, who have shaped me into what I am today. All the credit of this workgoes to them. May Lord Dhanwanthri bless all with Hitayu and Sukhayu who helpedme directly and indirectly in completing this work. Prasanna Kumar K Effect of Udvarthana in Sthoulya
  6. 6. List of TablesTable Content Page no.no.1 Paryaya of Sthoulya 062 Direct Aharatmaka Nidana 143 Indirect Aharatmaka Nidana 154 Viharatmaka Nidana 155 Manasika Nidana 156 Anya Nidana 167 Important Nidana with its features 168 Sthoulya Lakshana 259 Sthoulya Upadrava 2710 Ahararupi Pathya – Apathya 3211 Vihararupi Pathya – Apathya 3312 Different constituents of lipoprotein 3613 Normal limits of blood cholesterol 3914 Distribution of adipose tissue. 4015 Role of different genes 4616 Interpretation of BMI 5217 Drugs, there mode of action and adverse effects 5818 Difference between Langhana and Rookshana 6019 Effects of Rookshana karma: 6120 Samyak Rookshana Lakshana 6121 Rookshana athi yoga lakshana 6122 Rookshana Ayoga Lakshana 6323 Benefits of Udvarthana 6624 Sthoulya cases as per Age-wise Distribution 8325 Sthoulya cases as per Sex wise distribution 8326 Sthoulya cases according to their Religion 8427 Sthoulya cases according to their Socio-economical status 8428 Sthoulya cases according to their occupation 8429 Sthoulya cases according to their Prakruthi 8430 Sthoulya cases according to chronicity of disease 8531 Sthoulya cases according to Family history 8532 Sthoulya cases according to quantity of food consumption 8533 Sthoulya cases according to frequency of food consumption 8634 Sthoulya cases according to their Pana 8635 Sthoulya cases according to Rasa preferred 8636 Sthoulya cases according to Nidra kala 8637 Sthoulya cases according to their Adhyatana Agni 8738 Sthoulya cases according to their Poorvagni 8739 Sthoulya cases according to their Abhyahvarana shakthi 8740 Sthoulya cases according to their Jarana shakthi 8741 Sthoulya cases according to their Jatha Desha 8842 Sthoulya cases according to their Samvrudha Desha 8843 Sthoulya cases according to their Vyadhitha Desha 88 Effect of Udvarthana in Sthoulya
  7. 7. Cont…Table no. Content Page no.44 Sthoulya cases- Body frame 8945 Sthoulya cases- Educational status 8946 Sthoulya cases as their per Associated Features 8947 Sthoulya cases as per their Vihara 9048 Changes in chala spik, sthana and udara lambana 9049 Changes Ayathaupachaya utsaha hani 9050 Changes in Swedadhikyata 9151 Changes in Ayase Swasa 9152 Changes in Nidradhikya 9153 Changes in Adhika Kshuda 9254 Changes in Ahara matra 9255 Changes in Ahara kala 9256 Changes in Athi Pipasa 9357 Changes in Kshuda sahatva 9358 Changes in kshuda souhitya 9359 Changes in Alpa vyayama 9460 Changes in Anga gourava 9461 Changes in Anga sithilatha 9462 Changes in Gatra sada 9563 Statistical analysis of Subjective assessment 9564 Changes in weight 9765 Response in weight 9766 Changes in BMI 9867 Response in BMI 9868 Statistical analysis of changes in weight and BMI 9969 Response in chest circumference 10070 Response in abdomen circumference 10071 Response in hip circumference 10072 Response in Mid-arm circumference 10173 Response in Mid-thigh circumference 10174 Statistical analysis of Circumference of Chest, 102 Abdomen, Hip, Mid-arm, Mid-thigh75 Decrease in Total cholesterol level 10276 Changes in Total cholesterol 10377 Changes in HDL 10378 Increase of HDL level 10479 Changes in LDL 10480 Decrease of LDL level 10581 Changes in Triglycerides 10582 Decrease of Triglycerides level 10683 Statistical analysis lipid profile 106 Effect of Udvarthana in Sthoulya
  8. 8. Contd..Table Content Page no.no.84 Age wise distribution of survey patients 10785 Sex wise distribution of survey patients 10786 Religion wise distribution of survey patients 10787 Nature of work wise distribution of survey patients 10888 Diet wise distribution of survey patients 10889 Height wise distribution of survey patients 10890 Weight wise distribution of survey patients 10991 B.M.I wise distribution of survey patients 10992 Synonym of Sthoulya with modern interpretation 11093 Common Indian preparation with kcal.of energy IX94 Activities and caloric burn for different weight X95 Recommended energy intake for age, height, & weight X96 Height and weight for women of different ages XI97 Height and weight for men of different ages XI98 Common Indian cereals with their nutritive value XII99 Common Indian vegetables with nutritive value XII100 Miscellaneous Indian foodstuff with nutritive value XIII101 Reducing and weight maintenance diet of high cost XIII102 Reducing & weight maintenance diet of medium cost XIV103 Reducing and weight maintenance diet of low cost XIV Effect of Udvarthana in Sthoulya
  9. 9. Abbreviations Abbreviations(1) Cha. sam - Charaka samhita(2) Su. sam - Sushruta samhita(3) As. San - Astanga sangraha(4) As.Hr. - Astanga hridayam(5) Sha. sam. - Sharangadhara samhita(6) Bh.Pr. - Bhava Prakasha(7) Ma.Ni. - Madava Nidana(8) Yo.Ra. - Yogarathnakara(9) Ka. san - Kashapa samhita(10) Ra. vai - Rasa vaisheshika(11) su - Sutrasthana(12) vi. - Vimanasthana(13) sha - Shareera(14) ni - Nidanasthana(15) si. - Siddisthana sthana(16) chi. - Chikitsasthana(17) khila - Khilasthana(18) Ut. - Uttarasthana(19) BT - Before treatment(20) AT - After treatment(21) Dif. - Difference Effect of Udvarthana in Sthoulya
  10. 10. Introduction Scientific and technological progress has made man highly sensitive andcritical; there by giving rise to different types of health problems. Theadvancement of industrialization and communication is contributing towardssedentary life styles, in turn causing chronic non- communicable diseases likediabetes mellitus, hypertension, cancer, ischemic heart disease, cerebro-vascularaccidents, atherosclerosis, varicose veins etc. Obesity being the risk factor forthese diseases and hence prevention of obesity will decrease the chances of suchdiseases. Excess of fat is a disadvantage rather then an asset; it may “lengthenthe waist line” but “shortens the life line” of the individual by imposing an extraburden on all the systems of body. Inspite of advanced technology and researches, the modern medicine isfailing to give the best result for obesity, due to its multifactorial nature. Likeother diseases, obesity is mostly the result of factors like heredity, environmentor food, but it is difficult to decide the involvement of prime factor. It is notpossible to change heredity; it is difficult to change environment, but relativelyeasy to change food habits and life styles. Hence intervention at this level is need 1of the hour. Obesity is a major health problem in both developed and developingcountries. The exact estimation of prevalence is difficult as the standardizeddefinition is lacking. In countries like USA, approximately 55% of population inthe age group of 20-70 years is suffering from this problem. A study conductedin Delhi shown that approximately 25% of populations are obese in urban areas.Another study conducted in United States, showed increase in sudden death rateamong men and women with at least 20% overweight, which clearly shows thereduced life span due to its incidence. Ayurveda, the science of life, had given much importance to primary andsecondary preventions of diseases. Acharya’s have explained at length thevarious procedures that are to be implemented under Dinacharya and Ritucharya.These are advocated under a branch – Swasthavritta, which explains theprevention of diseases at different levels. The procedures like Abhyanga,vyayama, Udvarthana are explained in Dinacharya with an aim of maintaining Effect of Udvarthana in Sthoulya
  11. 11. Introductionone’s own physique in moderation. In Dasha vidha pareeksha, samhananapareeksha is to be examined to determine the compactness of dhatu i.e. the frameof the body, which is essential in the treatment context. Sthoulya is the nearest clinical entity for obesity in Ayurveda. Forcausation of Sthoulya, excessive intake of calories with a decreased expenditureis the main reason. With a view of preventing excessive consumption, only twoAnnakala are specified with intermediate period of 8-10 hours. While decidingthe Ahara to a person, the 8 factors (Ashta vidha Ahara Vishesha ayathana) areprescribed which includes the assessment of quantity, quality and composition.These eight principles incorporate all the modern parameters described in thecontext of nutrition. Considering the difficult nature of disease, obesity can bebetter prevented rather than treated. In ayurveda, obese persons are includedunder Asta Nindita purusha (Athi Deerga, Athi Hraswa, Athi Stoola, AthiKrusha, Athi Goura, Athi Sweta, Athi Roma and Aroma). The reason fordifficult nature being the involvement of Tridosha and affliction of sapta dhatu.It is also mentioned that the preferred constitution for an individual should be 2emaciated rather than obese. The existing obesity treatment options, in modern medicine includesdrugs like Fenfluramine, Dexfenfluramine and Sibutramine which acts asappetite inhibitors have with of adverse effects and cannot be used for more thanthree months. The diuretic and purgatives drugs are also used to treat obesity,but the action is for shorter term, and the patients again put on weight aftercessation of treatment. Some devices like vibrators are being used for locallipolytic action. Nutritional combinations (synthetic nutritional compounds) areexpensive and they too have untoward effects.In the present context Ayurveda offers a ray of hope in treatments like lekhanabasti, virechana, Udvarthana along with some internal medicines like Navakaguggulu, trayodashanga guggulu etc. The periodical Shodhana has also provenits efficacy. Among these therapies, the internal administration of guggulu hascertain limitations like gastric irritation, constipation etc. The administration oflekhana basti is to be undertaken for prolonged period and administration of Effect of Udvarthana in Sthoulya
  12. 12. Introductionwhich requires medical supervision. On contrary, Udvarthana is a procedurewhich can be undertaken daily with a preliminary training to the individual. It’sefficacy has been proved in reduction of Hyperlipidemia in the earlier studies;but its efficacy in reducing body weight has not yet studied. The observation atour hospital-conducted studies on the same over considerable samples showssignificant reduction in body weight in a very short duration of time with noadverse effects. Before and after Udvarthana, purgation was given. To document and analyze this procedure for statistical interpretation, thestudy entitled “ Effect of Udvarthana in Sthoulya” was undertaken. The effect ofUdvarthana in reducing weight and its relationship with serum lipid values wasalso considered. The whole dissertation consists of three studies under the followingheadings.  Conceptual study  Clinical study and 3  Survey studyConceptual study This part of the study deals with the literary review of sthoulya asexplained in classics with spatial reference to its Paribhasha, Nirukti, Historicalbackground, Nidana panchaka and Chikitsa etc. In further, the concept of obesity is explained considering from lipids toetymology, etiopathogenisis and treatment etc. No correlation was made inbetween and so that it can be interpreted in discussion chapter. The last part of this conceptual study includes the review of Udvarthana.It includes the Nirukthi, Paribhasha, etc of Udvarthana. For better understandingof this procedure, the principles of Rookshana are considered, as it is one amongthe Rookshana karma. Hence Rookshana is also explained in brief givingimportance for its practical approach. Effect of Udvarthana in Sthoulya
  13. 13. Introduction Clinical study This part of the study deals with the materials and methods. The methodsinclude the study design, reason for selecting design, objectives, selectioncriteria, subjective and objective parameters for assessments. The materials include the drug review, method of preparation ofUdvarthana dravya, procedure etc.Survey study As exact incidence and prevalence rates of obesity are not available, anattempt is made to survey the patients attending the OPD to assess the incidencerate. The study was carried out for thirty working days.All the observations, data and results are tabulated in the observations andresults section along with pictorial presentation. Based on the conceptual studyand results, a critical analysis was made in discussion part. In this chapter rightfrom the review of literature to clinical and survey study, discussions are carriedout. It also includes the probable mode of action of Udvarthana on sthoulya and 4also on lipid profile.In conclusion and summary chapter the dissertation is concluded. Here the wholeof the work is sum up with few important outcomes. Last but not least this dissertation include bibliography and appendixwhere some of the tables which are important for clinical study are enclosed,which includes case sheet, master chart, diet chart etc, helping the reader toverify the things wherever required. Effect of Udvarthana in Sthoulya
  14. 14. Review of literature-Sthoulya Sthoulya Paribhasha The word “Sthoola” is derived from root “Sthu” with suffix “ach” whichstands probably for “Thick” or “Solid” or “Strong” or “Big” or “Bulky”. Thedifferent meanings denoted by various Granthakara’s can be summarized asbelow- Shtulasya bhavam Sthoulyam – vachaspathyam (6/358) Sthulayathi te cha athaha Sthoulyam- vachaspathyam (6/358) Sthula paribhrane- Amarakosha (Nanartha varga 204) Sthulayathi Sthula Brumhane ach- Hemachandra Sthula sthiryate barhi asmavat- Bruhaspathi 5 Sanchaya Pravachana madhyam trike Sthulatha- Koutilya (patala 1/10) Medini opines Sthoola as “koota” or “samuha” which means the cluster.The human with large frame is known as “Sthoola” and “Sthoulya” is anadjective of the word “Sthoola”. Dictionaries give the meaning of “Sthoola” as: Large  Great Bulky Huge Fat Corpulent The word “Sthoola” is also used as synonym for some drugs like Khanda,Priyangu, Rakta lashuna, Ikshu etc. Effect of Udvarthana in Sthoulya
  15. 15. Review of literature-Sthoulya Sthoulya Nirukthi Different scholars had given their contribution in defining Sthoulya.Among them are:  A person having heaviness and bulkiness of the body due to extensive growth especially in Udaradi region is termed as “Sthoola” and this state (Bhava) of Sthoola is called as “Sthoulya”1.  Athi Sthoola has been defined as a person who on account of the inordinate increase of fat and flesh is distinguished with pendulous buttocks, belly and breasts and whose increased bulk is not matched by a corresponding increase in energy2. Sthoulya Paryaya Table no.01 showing Paryaya of Sthoulya as per different texts: 6Sl. Paryaya Ch. Su. As. Ka. Ma. Sha Bh. Yo.No Sam Sam San Sam Ni Sam Pra Ra1 Sthoulya + + + + - - + +2 Athi Sthoulya + + + - - - + +3 Sthoolata - + + - - - - -4 Sthoolatwa - - + - - - - -5 Sthavima - - + - - - - -6 MedoRoga - + + - + + + +7 MedoDosha + - - - - + + +8 Medovriddhi - - - - - - + +9 Medovikara - - - - - - + -10 Medogada - - - - - + + -11 Medopushti - - - - - - - +12 Medadushti - - - - - - - +13 Athipushti - - + - - - + -14 Pushti + + + + - + + +15 Upachaya + + + + - + + +16 Jathasya - + - - - - - -17 Brumhana + - + + - - - -18 Medaswita - - - - - - - +19 Medurata - - - - - - - + Effect of Udvarthana in Sthoulya
  16. 16. Review of literature-Sthoulya Historical backgroundI) Reference in Vedas: Ayurveda is known to be upaveda of Artharvana Veda. We find somescattered reference of sthoulya in this Veda like:“Pivasi ……. Naiva Majja svahatam” | 1/11/4MEDASI :“ye kilaarlana tarpayanthi ye dhatena ye va kyo Medasicha si mam”| 4/27/5II) Reference in samhita:a. Brihatrayi; In the big triads of Ayurveda i.e. Charaka samhita, Sushrutha samhita andAstanga sangraha, we find many reference regarding sthoulya.1.Charaka Samhita Acharya Agnivesha has explained sthoulya under the heading of Ashta 7Nindita in Sutra Sthana 21st chapter. Here the descriptions of Etiology,pathogenesis, symptomatology, along with its treatment and diet have beenexplained. Athi sthoulya is also mentioned as one of the Kaphaja Nanatmajavikara.2. Sushrutha Samhita In Sutrasthana 15th chapter “Dosha Dhatu Mala Vignana” the descriptionof sthoulya has been explained which includes causes, symptoms, signs andtreatment. In Sutra sthana 35th chapter the treatment principles of sthoulya hasbeen explained3. 3. Ashtanga Sangraha It has been described the different aspects of sthoulya in Sutrasthana “Dwividhopakramaniya” chapter. It is also explained that sthoulya is “Athi Brumhanajanya” Vyadhi. Effect of Udvarthana in Sthoulya
  17. 17. Review of literature-Sthoulya b. Laghutrayi 1. Madhava Nidana: He is the first author to describe this disease under separate heading called “Medo Roga” in 34th chapter. He has mentioned Nidana, Lakshana and Samprapthi of this disease. 2. Sharangadhara Samhita: This textbook is known for its many unique things like Nadi pareeksha, clear definition of pharmacological terms etc. this author has explained madhu as the single drug treatment for Medovriddhi4. 3. Bhava Prakasha: Author has stressed more on the treatment aspects compared to Brihatrayi. Acharya Bhava mishra has explained regarding a popular Dhupa called “Malayanila Dhupa” in 39th chapter of Chikitsa sthana. He has also 8 explained regarding various Lepa and Udvartana to treat sthoulya. This author has explained sthoulya in separate chapter.c. Other Classical Texts:1. Bhela Samhita: It is one of the popular texts of Ayurveda. In 11th Chapter of sutrasthana,various aspects of Sthoulya have been explained.2. Vangasena Samhita:In this classical textbook, Medo Roga Chikitsa is explained in 16th chapter.3. Yogaratnakara: Sthoulya is explained under a separate chapter. Many of the formulationsto treat Sthoola are explained. Effect of Udvarthana in Sthoulya
  18. 18. Review of literature-Sthoulya4. Chakradatta: Acharya Chakrapani datta has explained treatment of Sthoulya in 36thchapter.5. Kashyapa Samhita: As this book gives more importance for “Koumarabruthya” and “Prasuthitantra”, hence Acharya Kashyapa have described “Medasvi Dhatri Chikitsa”5.Another specialty of this text is that Rakta mokshana is explained as Chikitsa forSthoulya.6. Bhaishajyaratnavali: It is famous for various treatment and preparations of medicines. In 39thchapter Sthoulya Chikitsa is explained.7. Gada Nigraha: 9 In 31st chapter, Sthoulya Roga and its Chikitsa is explained.8. Rasaratna Samucchaya: This book of Rasashastra, has explained Sthoulya in 18th chapter.9. Nidana Chikitsa Hastamalaka: This book of Ayurveda has been written in modern times by VaidyaRanajit Ray Desai. Here Sthoulya is explained in second volume. Effect of Udvarthana in Sthoulya
  19. 19. Review of literature-Sthoulya Physiological consideration of Meda Dhatu:Utpathi: When the sukshma bhaga of Mamsa dhatu comes in contact withMedodhatwagni then Meda dhatu is formed. Due to ambu guna present inMedas, sneha guna is increased. Mamsa dhatu gets paka due to its Agni andambu guna present in it forms Medo dhatu6.Guna – Karma: Medo dhatu is having the guru and Snigdha guna. It gives bala andbhrumanatva to the body7. It produces sneha and sweda in the body; it makesdrudata of shareera and gives poshana to Asthi dhatu8. Sneha in the body is ofthree types: 1.In the form of Medas which is Sandra & like Ghrutha 2. In the form of Vasa, which is present in Mamsa 3. In the form of Majja, which is present in Asthi9. 10Medodhara Kala: It is the third Kala, present in Udara and sukshma Asthi10.Medovaha Srotas and its Vidha Lakshana: These srotas are two in number. The moola is kati and vrukka. Vidhalakshana are Sweda (sweating), Snigdhata in anga (oily body), talu shosha(dryness of palate), stoola shopha (large swelling) and Pipasa (thirst).11Meda Dhatu Mala: Sweda is the mala of Meda dhatu12.Meda Dhatu Upadhatu: Snayu is the upadhatu of Medas13. Effect of Udvarthana in Sthoulya
  20. 20. Review of literature-SthoulyaMeda Dhatu Pramana: Two anjali is said to be the quantity of Meda dhatu.Meda sara purusha lakshana: Adhika snehansha in varna , swara, netra, kaksha, loma ,nakha, danta,oushta, mutra and pureesha. The person will have Dhana, Ishwarya, Sukha,Upabhoga. He will be Daana-sheelata, Saralata, Komalatha and Bhavakasuchaka14. It is also mentioned that these persons will have large body and unable toperform heavy work15.Meda Dhatu Vridhi Lakshana: Snigdhata of Shareera, vridhi of Udara and parshwa, kasa, swasa, hikka,dourgandha of shareera are seen as Meda vridhi lakshana16. It is also mentionedthat these persons will have Srama and increase in size of Spik, sthana and 11Udara17.Meda Dhatu Kshaya Lakshana: The depletion of this dhatu are seen as Plehavridhi, Sandhi Shunyatha,Rukshyata and Iccha of Athisnigdha and Mamsa18. The other symptoms areShunyata of Kati, Krusha shareera19. Effect of Udvarthana in Sthoulya
  21. 21. Review of literature-Sthoulya Sthoulya Nidana Nidana is an important factor for manifestation of any disease. Many atimes a disease can be diagnosed on the basis of nidana itself as in case of“Mrudbhakshanajanya Pandu”. The synonyms of nidana are Nimitta, Hetu, Ayatana, Prathyaya, Uttana,and Karana. Nidana can be broadly classified as Bahya nidana, which includesahara and vihara, and Abhyantara nidana being the Dosha and Dushya.Abhyantara nidana will be discussed in the context of Samprapthi. Bahya nidana can be compared with etiological factors in contemporaryscience. The etiological factors are scattered in classical textbooks of Ayurvedaunder different heading like: 1. santarpana karaka nidana20 2. Medo Roga hetu21 3. Athi sthoulya hetu22 12 4. Medo Mamsavaha srotodusti hetu23 5. Prameha Hetu24 6. Kapha Vruddhikara Hetu25All of these can be summarized as follows: 1. Aharatmaka nidana 2. Viharatmaka nidana 3. Manasika nidana 4. Sahaja nidana 5. Anya nidana1. Aharaja nidana: Food plays a major role in formation of Sthoulya and hence it is rightlysaid that wholesome and unwholesome foods are responsible for happiness andmisery. Effect of Udvarthana in Sthoulya
  22. 22. Review of literature-Sthoulya Aharaja nidana are wide spectrum of etiological factors, which is havingvariation in Ahara krama at one end, and Rasadi factors at another end. Thefollowing are the Aharaja Hetu: 1. Adhyashana 2. Athi matra ahara 3. Athi sampurana 4. Guru, sheeta, pichila, snigdha guna ahara 5. Madhura Rasapradhana ahara 6. Specific dravya pradhana aharaAdhyashana: Food that is consumed before the digestion of previous meal is called asAdhyashana. Here the patient will be not following the ahara ashta vidhavisheshayatana. 13Athi matra Ahara: Excess consumption of food is called as Athi matra Ahara sevana. Herethe consumption of food is related not only for quantity of intake but also thefrequency of intake. As the formation of Rasa is more, it over- nourishes theDhatu of the body; there by leading to Brihath Shareera.Athi sampurana: Intake of food up to ones full belly is called as Athi sampurana. To assessthe quantity of food in take the parameters had been explained in the classics26.Guru, sheeta, pichila, snigdha guna ahara: All these guna have an affinity towards the Kapha and the Medas there byleading to increase in their quality and quantity. More over due to Picchila andSnigdha guna, it causes the obstruction of the Vata in the srotas, in turn leads tosandukshana of Agni. Effect of Udvarthana in Sthoulya
  23. 23. Review of literature-SthoulyaMadhura Rasapradana ahara: This Madhura Rasa is having the Kapha prakopaka property because ofwhich there will be increase of Kapha and Medas. When the Madhura Rasa isadded to Snigdha guna then there will be more vitiation of Dosha.Table no.02 showing Ahara, which directly cause Sthoulya:Sl Nidana Ch. Su. As As Ma Bh YoNo Sam Sam San Hru Ni. Pr Ra.1 Adhyashana - + - - - - -2 Athi sampurana + - + - - - -3 Athi brumhana - - - + - - -4 Guru ahara + - + - - - -5 Madhura ahara + + + - + + +6 Kaphakara ahara - + - - + + +7 Snigdha ahara + - + - - - - 14 Some of the Nidana explained in different context can be considered forunderstanding Sthoulya Nidana.Table no 03 showing indirect Aharatmaka Nidana of Sthoulya:Sl Nidana Ch. Su. As As Ma Bh YoNo Sam Sam San Hru Ni. Pr Ra.1 Athibhojana + - - - - - -2 Sheeta ahara + - - - - - -3 Navanna + - - - - - -4 Navamadya + - - - - - -5 Gramya Rasa + - - - - - -6 Paya vikara + - + - - - -7 Dadhi + - - - - - -8 Sarpi + - + - - - -9 Ikshu + - + - - - -10 Guda + - - - - - -11 Mamsa + - - - - - -12 Godhuma + - - - - - - Effect of Udvarthana in Sthoulya
  24. 24. Review of literature-SthoulyaTable no.04 showing viharatmaka Nidana of Sthoulya:Sl no Nidana Ch. Su. As Ma Bh Yo Sam Sam Hru Ni. Pr Ra.1 Avyayama + + - + + +2 Avyavaya + - - - - -3 Divaswapna + + - + + +4 Sukha shayya + - + - - -5 Gandhamala dharana + - - - - -Table 05 showing Manasika Nidana of Sthoulya:Sl Nidana Ch. Su. As Ma Bh YoNo Sam Sam Hru Ni. Pr Ra.1 Harsha Nitya + - + - - -2 Achintana + - + - - - 153 Priyadarshana + - - - - -Table 06 showing Anya Nidana of Sthoulya:Sl Nidana Ch. Su. As Ma Bh YoNo Sam Sam Hru Ni. Pr Ra.1 Ama Rasa - - - - + -2 Snigdha Madhura basti + - - - - -3 Tailabhyanga + - + - - - Effect of Udvarthana in Sthoulya
  25. 25. Review of literature-SthoulyaTable no.07 showing important Nidana of Sthoulya with its features:Sl. Nidana Mahabhuta Rasa/Guna/ VitiationNo Predominance Veerya/Vipaka1 Guru ahara Pruthvi +Ap Madhura Rasa Kapha-Meda2 Snigdha ahara Pruthvi +Ap Madhura Rasa Kleda3 Picchila ahara Pruthvi +Ap Madhura Rasa Kapha-Meda4 Sheeta ahara Ap Madhura Rasa Vata-udaka5 Madhura Rasa Pruthvi +Ap Snigdha, guru Kapha-Meda6 Go ksheera Ap Madhura KaphaMeda7 Mahisha ksheera Ap + Pruthvi Athi sneha Kapha-Meda8 Dadhi Ap + Pruthvi Kapha-Meda9 Ghritha Agni + Ap Snigdha Kapha-Meda10 Ikshu Ap+ Madhura Kapha11 Phanitha Pruthvi + Ap Guru TriDosha12 Guda Pruthvi Madhura, kashaya Kapha-Meda13 Anupa Mamsa Ap + Pruthvi Madhura Rasa Kapha14 Athi Nidra - Tamo guna Kapha15 Sukha shayya - Tamo guna Kapha 1616 Divaswapna - Tamo guna Kapha17 Avyayama - Tamo guna Kapha18 Athi vyayama - Rajo guna Vata19 Jagarana - Rajo guna Vata20 Anashana - - Vata Effect of Udvarthana in Sthoulya
  26. 26. Review of literature-Sthoulya Sthoulya Samprapti It is defined as “the description of the evolution of the disease insequential order, commencing with Dosha-Dushya vaishyamya till the diseasemanifests completely. For the manifestation of a disease various derangedstructural and functional elements of the body are responsible and all such thingsare studied under Samprapti. The knowledge of Samprapti (also called as jathiand agathi) is very helpful to the physician both for accurate diagnosis and alsofor planning appropriate treatment. It is essential to know about “Ghataka” ofthe Samprapti because Samprapti vighatana itself is Chikitsa.Samprapti of sthoulya is understood as follows: 1. Samanya Samprapti of sthoulya 2. Samprapti Ghataka of sthoulya 3. Role of Ama in sthoulya 4. Analysis of important features of sthoulya 17Samanya Samprapti of sthoulya: The nidana of sthoulya will produces the Ama when there is anatmosphere in favour of them and prior to which there will be production ofreversible bond between Nidana- Dosha- Dushya27, which is must for themanifestation of the disease. This Ama after acquiring Madhuratwa along withsnehamsha, present in the body will produce vikrutha Medas. This will becomeobstacle for the nourishment of uttarottara dhatu resulting in under developmentof those dhatu. Accumulation of Medas resulting in Vata vridhi at koshta leadsto Athi sandukshana of Jataragni. This pradeepta Agni will be always in wants offood there by it makes a person to feel more of hungry otherwise leading tovarious derangements, but if food is taken it will nourish only the Medas. Thusthis vicious cycle results in the vridhi of certain anatomical region or all bodyparts. Effect of Udvarthana in Sthoulya
  27. 27. Review of literature-Sthoulya Samprapthi chakra Nidana sevana Ahara, Vihara, manasika Kostagni dusti Madhuratara anna Ama Rasa Medo Dhatwagni d t Atisneha utpatti Meda dhatu ati upachaya 18Beeja Ati Meda avarana Ati vrudha Meda dhatu causes anya dhatu Vata vrudhi in kosta dh Jataragni ati sandhukshana Anya dhatu asamyak upachaya Ati ahara sevana STHOULYA Effect of Udvarthana in Sthoulya
  28. 28. Review of literature-Sthoulya Samprapthi Ghataka Dosha: Kapha – Kledaka Vata - Samana, Vyana, Prana Pitta - Pachaka Dushya: - Rasa, Mamsa, Medha Agni: Jataragni - Pradeeptha Dhathwagni - Medadhathwagni manda. Ama: - Medadhathwagni manda janya Srotas: - Medovaha, Rasavaha Dusti prakara: - Sanga Udbhava sthana: - Amashaya Adhistana: - Vrukka, Vapa 19 Sanchara sthana: - Sarva daihika Vyaktha sthana: - All over body but mainly in Spik, Sthana, Udara. Vyadhi prakara: - Chirakari, Sadyasadyatha - Krucchrasadhya Roga marga: - Bhahya and Abhyantara Effect of Udvarthana in Sthoulya
  29. 29. Review of literature-SthoulyaBrief description about important Lakshana: 1. Meda- Mamsa Vrudhi: As it is a Meda Dhatwagni mandya janya vikara, the excess of formation of Medas along with its immediate poorva dhatu i.e. Mamsa dhatu is seen. The nidana like guru, picchila ahara and divaswapna and athi nidra will contribute to the vikara of Kapha. This Kapha is having the same qualities of Medas and hence Dosha-Dushya sammurcchana takes place leading for Vrudhi of Mamsa and Medas, which are Ama roopi. 2. Chalatwa of Spik Sthana and Udara: This is seen when more of Meda dhatu is present relatively more than Mamsa dhatu. Chalatwa is mainly appreciable in the Anatomical regions like Spik, Sthana and Udara. Here Medas is not properly adhered to the Mamsa dhatu and hence it moves freely giving rise to above 20 condition. 3. Ayatopachayotsaha: Because of the guru guna present in Kapha and Medas, it gives raises to vrudhita of tamasika guna of Manas in turn giving raise to sluggish movements to the body, and also due to Anga gurutwa this feature is seen. 4. Ayusrhasa: This lakshana is explained as one of the ashta Dosha of Sthoulya. The less span of life is seen, as it is one of the ashta nindita Vyadhi where Bahu Dosha are involved. When uttarottara dhatu formations are hampered, the Oja kshaya takes place, which is responsible for maintenance of ayu. Hence we see decreased lifespan in Sthoola purusha. Effect of Udvarthana in Sthoulya
  30. 30. Review of literature-Sthoulya5. Krucchra vyavaya: Shukra dhatu is responsible for vyavaya. When its rate of formation is reduced due to mandata of Meda Dhatwagni, there will be difficult in sexual act.6. Athi Sweda and Dourgandhya: Sweda is said to be mala of Medas. When there is increase in Meda dhatu, formation of its mala is also increased leading for excessive sweating. Due to excessive sweating, the Medasvi will have Durghanda in their body.7. Athi kshut and Pipasa: In sthoulya, vikrutha Vata will carry Agni from the Meda dhatu to amashaya, due to obstruction for the moment of Vata by picchilatha of Medas in the srotas of shakha. Hence pradeepthata of Jataragni is seen 21 leading for the symptoms like excessive thirst and hunger40. Effect of Udvarthana in Sthoulya
  31. 31. Review of literature-Sthoulya Poorvaroopa It refers to the features, which indicates the forth-coming disease. Itusually happens during (this corresponds with) fourth kriya kala called “Sthanasamsraya”. Clinically, this is important for early diagnosis, treatment andprognosis. Mild exhibition of actual features of disease itself can be consideredas Poorvaroopa.Poorvaroopa is of two types: 1. Samanya poorvaroopa 2. Vishesha poorvaroop Samanya poorva rupa gives the knowledge about forthcoming disease, butnot regarding the exact disease, where as Vishesha Poorvaroopa gives theknowledge regarding Dosha as well as the disease. 22 In the context of present disease, none of the Acharayas have stressedupon the poorva rupa, but it doesn’t mean that they are absent; in turn it is verydifficult to identify the features of poorva rupa during the process of diseasemanifestation. As per the directions given in Vata Vyadhi28, Urakshata29,Thrushna30 chapters, the initial manifestations of Sthoulya related symptomscould be considered as the premonitory symptoms or Poorva Rupa of Sthoulya31.Bahu Drava Sleshma and abhada Meda are two morbid components involved inpathogenesis of Prameha32, which are found vitiated in Sthoulya also. So KaphaSanchaya and Meda Dusti lakshana related Poorvaroopa of Prameha andMedovaha Srotodusti lakshana described by Acharya Sushrutha33 can beconsidered as poorva rupa of Sthoulya. In contemporary science this is termed as “Premonitory features” as seenin the conditions like leprosy etc. Effect of Udvarthana in Sthoulya
  32. 32. Review of literature-Sthoulya Rupa When the Vyadhi kriya kala is in fifth stage (Vyakthavastha), the disease will produces the features called as “Rupa”. These rupa will indicate the manifestation of disease34. Rupa is having synonyms like Samsthana, Vyanjaka, Linga, Lakshana, Chinna, and Akruthi35. Rupa includes both subjective symptoms as well as objective signs. This is the stage when Dosha -Dushya Sammurcchana is completed. Dosha -Dushya Sammurcchana is of two types:1) Prakruthi Sama Samavetha: Here the nature of mixing up of Dosha and Dushya is not intensive and hence both involved in a particular disease continue to maintain some degree of their identity in resultant disease. Therefore, clinically it is not difficult to identify the involved Dosha and Dushya based on lakshana. 232) Vikruthi Vishama Samavetha: The nature of mixing up of Dosha and Dushya are so much intensify that, it will be very much difficult to assess the Dosha and Dushya involved on the basis of the lakshana of disease. Ex. In Prameha, “Prabhuta Avila Mutrata” is neither the feature of Kapha nor the Medas. Sthoulya is a disease where inspection itself is suffixes for the diagnosis. In spite of that our Acharayas have explained some of the signs and symptoms, based on which it can be differentiated from other disorders where enlargement of body is seen as in case of Sarvanga shotha. Effect of Udvarthana in Sthoulya
  33. 33. Review of literature-Sthoulya The lakshana of Sthoulya had been described under different headings like:1. Sthoulya Lakshana362. Medo Roga Lakshana373. Sthoulya Ashta Dosha374. Medo Vrudhi Lakshana385. Medovaha Sroto Dusti Lakshana39 All the lakshana can be broadly classified as:1. Sthoulya Pratyatmaka Lakshana2. Sthoulya Samanya Lakshana1. Sthoulya Pratyamtaka Lakshana: The following are the diagnostic features of Sthoulya:a) Medo Vridhi (increase in fat) 24b) Mamsa Vridhi (increase in flesh)c) Chala Spik (Pendulous buttocks)d) Chala Udara (Pendulous abdomen)e) Chala Sthana (Pendulous breast)f) Ayatopachayotsaha (sluggish movement of body)2. Sthoulya Samanya Lakshana: Rest of the symptoms present in the table shows Samanya lakshana of sthoulya. Effect of Udvarthana in Sthoulya
  34. 34. Review of literature-SthoulyaTable no.08 Showing Sthoulya lakshana given by different authors:Sl. Lakshana Ch. Su. Ma Yo. Bh. Chi. Bas.No Sam Sam Ni Ra Pr San Raji1 Medo Vridhi + - + + + + +2 Mamsa Vridhi + - + + + + +3 Chala Sphik + - + + + + +4 Chala Udara + - + + + + +5 Chala Sthana + - + + + + +6 Ayatopachayotsaha + - + + + + +7 AyushahRasa + - - - - - -8 Javaparoda + - - - - - -9 Krucchra vyavaya + - + + + + +10 Dourgandha + + + + + + +11 Dourbalya + - + + + - +12 Swedadhikyata + + + + + + +13 Athi kshut + + + + + + +14 Athi pipasa + + + + + + +15 Kshudra swasa - + + + + + +16 Krathana - + + + + + -17 Gatra sada - + - - - + -18 Gadgada - + - - - - - 2519 Moha - - + + + + -20 Swapnadhikya - + + + + + -21 Alpa prana - - - - - + - Effect of Udvarthana in Sthoulya
  35. 35. Review of literature-Sthoulya Upadrava This manifests in last kriya kala. The condition in which furtherdevelopment of disease takes place after Rupavastha is called as “Bhedavastha”or “Upadrava”. 41 Upadrava is mainly due to the chronicity of the disease in which a propertreatment is not given. Sometimes due to virulence of Dosha-Dushyasammurcchana, with in a short period, this state is seen. It is sequel of the main disease. The sequel is so called because it isconsequent of the disease. The main disease is the primary and upadrava arebeing secondary. Upadrava may be major or minor ailment when compared withprimary disease. Usually, these will disappear when the primary disease istreated, but sometimes a separate treatment may require for upadrava due to itsmore virulence than the primary disease. Hence, a physician should always becapable of eliciting upadrava from the Roga and should give a proper treatmentfor what so ever is required. 26 As Sthoulya is an Asadhya Vyadhi, it will always have the tendency toexhibit upadrava. The concept of Sthoulya Ashta Maha Dosha42 can beconsidered as upadrava itself. Here Agni and Vayu are important factors forupadrava. Prakupita Vata due to its obstruction by Medas will make theSandukshana of Agni. This Pradeepta Agni digests the food as quick as fireburning the forest. Hence there will be Athi kshudha in the Sthoola. If the properquality and quantity of food is not supplied to this Teekshnagni, it will producehazardous effect, which may cause even death. Shiva Das Sen commenting on Charaka samhita states that “Vikaramdaruna” should be considered as Prameha, Pidaka, Jwara, Bhagandara, Vidradhiand Vata Roga. Dalhana opines that among the said Upadrava any one or all of them maypresent while commenting on “Vikarana anyatamam”. Same author oncommenting “Prapya panchatwam upayati” says that the person dies due to Effect of Udvarthana in Sthoulya
  36. 36. Review of literature-Sthoulyaupadrava. Bhava mishra and Yogaratnakara have used the word “Sudustara” inthe place of upadrava shabda.Table no.09 showing the Sthoulya upadrava:Sl. Upadrava Ch. Su. As. Bh. Yo. Ba. Chi.No Sam Sam Hr Pr Ra Raji San1 Prameha + + + + - + +2 Pidaka + + + + - - -3 Jwara + + + + - + +4 Bhagandara + + + + - + +5 Vidradi + + + + - - -6 Vata Roga + + - + - - -7 Udara - - + - - - -8 Urusthamba - - + - - - -9 Kusta - - - + - + +10 Visarpa - - - + + - +11 Athisara - - - + + - +12 Arshas - - - + + - +13 Slipada - - - + + - +14 Apachi - - - + + - +15 Kamala - - - + + - + 2716 Krimi - - - + - - +17 Thrushna - - - - - + -18 Moha - - - - - + -19 Vrana - - - - - + -20 Mutra krucchra - - - - - + -21 Kasa - - - - - + - Effect of Udvarthana in Sthoulya
  37. 37. Review of literature-Sthoulya Sadhyasadhyata Ancient scholars keeping in view of success rate of treatment haveexplained the concept of Sadhyasadhyata. The prognosis of the disease dependsupon the factors like Nidana, Kala, Desha, Bala, Ashraya, and Lakshana etc. Ifritu and Dosha (ritu swabhava Dosha and Vyadhi utpadaka Dosha) are similarthen the disease will be of bad prognosis (few exceptions like Jwara). If Doshaand Dushya are of similar nature then the disease is Asadhya43 (exceptions likeKaphaja Prameha). Hence the wise physician must analyze samprapthi ghatakafirst, and then start the treatment after explaining the prognosis of the disease tothe patient, or else if he handles the patient with bad prognosis he will lose bothname and fame44. So the knowledge of sadhyasadhyata is essential whileselecting medicine and therapy for the particular disease. Considering the above general principles, Sthoulya is treated as anAsadhya Vyadhi as there will be involvement of similar Dosha (Kapha) and 28Dushya (Medas). As it is a slow progressive condition continuous medicamentalong with general instruction are required. Hence the obese patients are rightlydescribed under “Ashta nindita purusha”. Brihatrayi opines that when comparison is made between Krusha andSthoola, the Krusha is better for the treatment, because it is difficult to bringback the Agni, Vata and Medas to equilibrium in case of Sthoulya45. As it is one of the Beeja swabhavaja Vyadhi, classical texts haveconsidered it as Asadhya for Chikitsa46. Effect of Udvarthana in Sthoulya
  38. 38. Review of literature-Sthoulya Sthoulya Chikitsa The process by which dhatu samyatha is achieved that is called as“Chikitsa”. As Sthoulya is a Santarpanajanya Vyadhi, Apatarpana Chikitsashould be given. To achieve the same our Acharayas have explained differenttypes of treatment modalities. As Vata, Kapha and Medas are important vitiatedfactors in Sthoulya, correction of these should be the main line treatment.Sthoulya is a multifactorial disease having involvement of factors like guruBhojana, athi Nidra etc., which will cause mandata of Meda Dhatwagni andvridhi of Jataragni, as a result of formation of uttarottara Dhatu will behampered. Moreover due to presence of Ama this disease requires holisticapproach to bring the Dosha and dhatu to their samyavastha, which is seen as“Laghavatha of Shareera”. The following are the different type of Chikitsa which are applied to treatSthoulya 29 1. Santarpanajanya Vyadhi Chikitsa 2. Satatakarshana Chikitsa 3. Guru cha Atarpana 4. Langhana Chikitsa 5. Pathyapathya with special importance to nidana parivarjana. Santarpanajanya Vyadhi Chikitsa: Procedures like Vamana, Virechana, Rakta mokshana, Vyayama,Upavasa and Swedana are been explained for all the disease, which areoriginated because of Santarpanakaraka ahara and vihara. Apart from the above,other medicines like honey with Haritaki choorna Rooksha Annapana,Triphaladi quatha, Musthadi quatha and Kustadi choorna47 are also advised totackle with Sthoulya. Effect of Udvarthana in Sthoulya
  39. 39. Review of literature-SthoulyaSatatakarshana Chikitsa: For the Sthoola rogi, karshana should be done continuously. Because of thekarshana there will be depletion of Mamsa as well as Meda dhatu, resulting inLaghavatha of Shareera48. Guru cha Atarpana: This is one of the basic line of treatment, which is mainly adopted, in theselection criteria dietary drugs for Medasvi. Meaning of “Guru Cha Atarpana” isthat those drugs which are heavy for digestion and having the Atarpana Guna.As the Jataragni is in Pradeepta avastha, hence guru guna dravya should beprescribed and at the same time these drugs should not nourish the dhatu. Drugshaving above properties are Prashatika, Priyangu, Shyamaka, Yava, Kodrava,Mudga, Kulatha Patola, Madhudaka etc.49Langhana Chikitsa 30 Acharya Charaka is explained about 10 different types of Langhana,which can broadly classify as1. Shodhana rupi langhana2. shamana rupi langhana1. Shodhana rupi langhana: Acharya Charaka has explained about the four types of Shodhana that canact as Langhana. They are:a. Vamanab. Virechanac. Niruha Basthid. ShiroVirechana Effect of Udvarthana in Sthoulya
  40. 40. Review of literature-Sthoulyaa. Vamana: This is the procedure done to expel out the utklista Kapha from the body.This procedure will aggravate Vata hence application of the same may not bechoice of therapy in Sthoulya.b. Virechana This is the choice of treatment for Pittaja vikara and also for Pittasthanagata Vata vikara as its action is seen in Pakvashaya also in the form ofVatanulomana. Hence this can be adoptable in the Sthoola.c. Niruha Basthi: To check the vikrutha Vata that is present all over the body, classical textshave explained about Basthi therapy, as it acts at the root level of Vata. ThisBasthi is of two types (Anuvasana Basthi & Niruha Basthi) depending on thedrugs used. In the context of Sthoulya, ancient scholars have explained about the 31administration of Niruha Basthi. Among all varieties of Basthi, Lekhana Basthistands in the first place to tackle the condition of Sthoulya.d. Shiro Virechana: This is done to expel the vikrutha Kapha present above neck. As it isexplained that “Nasa hi shiraso dwaram…” This may not have direct action overSthoulya, but it can defiantly helps to overcome some of the features of Sthoulyalike “Athi kshudha”. Effect of Udvarthana in Sthoulya
  41. 41. Review of literature-Sthoulya Pathyapathya This is the unique contribution of Ayurveda and explained for almost alldiseases. It plays an important role as much as of medicine and it is rightlymentioned that “if one follow Pathya, than there is no need of medicine and ifnot than also there is no use of therapeutic measures”. Acharya Charaka has stressed upon the Guru and Atarpana drugs as aspecial diet for Sthoola, which is already described. Commentators likeChakrapani50 and Gangadhara51 had mentioned that “sthoka bojana” or “Alpabojana” as the best karshana. They have also given weight-age for laghu androokshana ahara. Ahara dravya should be used after converting it in guruthrough samskara52. The following tables show various Pathya and Apathyaprescription for Sthoola. 32Table no.10 showing Ahararupi Pathya - Apathya for Sthoulya: Ahara varga Pathya ApathyaShuka dhanya Yava, Kodrava Godhuma, Navanna, shaliShami dhanya Mudga, Rajamasha, Kulatha, Masha, Tila ChanakaShakha varga Patola, vrunthaka Madhura phalaDravya Takra, Madhu, ushnodhaka, Dugda, draksha, Sarshapa Taila, Arista, Asava, navaneeta, grutha, dadhi Jeerna MadyaMamsa Rohita matsya Anupa, gramya Effect of Udvarthana in Sthoulya
  42. 42. Review of literature-SthoulyaTable no.11 showing Vihararupi Pathya - Apathya for Sthoulya: Pathya ApathyaSrama Jagarana Divaswapna AvyayamaVyayama Chintana Avyavaya Sukha shayyaShoka Krodha Nitya harsha AchintanaNitya bramana Sheetala jalapana 33 Effect of Udvarthana in Sthoulya
  43. 43. Review of literature-Obesity Lipids The term “lipids” is applied to a group of naturally occurring substances(plant and animal origin) characterized by their insolubility in water, greasy feeland solubility in some organic solvents.Lipid in diet: Lipids are consumed in the form of neutral fats, which are also known asTriglycerides. Triglycerides are made up of a glycerol nucleus and three fattyacids. These lipids form the major constituent in food of animal origin and muchless in food of plant origin. Apart from neutral fats, the usual diet also contains small quantities ofcholesterol and cholesterol esters.Digestion of lipids: The enzymes involved in the digestion of lipids are known as lipolyticenzymes. The tributyrase or gastric lipase present in gastric juice is not sufficientto digest the lipids due to its weak in terms of quality as well as quantity. The 34lipids are actually digested in small intestine. Bile salt takes key role in thedigestion. The other enzyme is pancreatic lipase1.Role of bile salts: The lipid molecules are insoluble in water due to its surface tension. Sothese molecules are not digested by any of the lipolytic agent. Due to thedetergent action of the bile salts, the lipids are made water-soluble and thisprocess is called as “Emulsification”. During this process the bile salts causeformation of aggregation of lipid in the form of “micelles”. The micelles containcholesterol, monoglycerides and fatty acids.Role of Pancreatic Lipase: It can digest only emulsified fat molecules. Pancreatic Lipase convertsmost of the Triglycerides into free fatty acids and monoglycerides but only a Effect of Udvarthana in Sthoulya
  44. 44. Review of literature-Obesitysmall part remains as diglycerides. The action of Enteric Lipase, present in smallintestine mucosa is negligible.Absorption of lipids: From the micelles, fatty acids, cholesterol and monoglycerides diffuseinto epithelia; cells in the mucosa of small intestine. The fatty acids with lessthan 12 carbon atoms diffuse directly into blood, which transports them throughportal vein to liver as unesterified fatty acids. The fatty acids with more then 12carbon atoms are converted into triglycerides by re-esterification. Now, thelipids remaining in the small intestine are aggregated into the chylo-microns bythe activity of Endoplasmic reticulum of the epithelial cells in the intestinalmucosa. Chylomicrons are mainly formed by Triglycerides and cholesterolesters and, are coated with layer of cholesterol, Phospholipids and some proteins.Chylomicrons cannot pass through the blood capillaries because of the largersize. So these lipid materials enter the lymph vessels and, are transported intoblood from lymph. 35Applied physiology: When digestion and absorption of lipids are affected, the stools becomefatty and bulky. This is called as “steatorrhea”. This occurs due to lack ofpancreatic enzyme during the disorders of exocrine part of pancreas. Thiscondition is also seen due to the absence of bicarbonate ions in pancreatic juice.Due to lack of bicarbonate ions, the bile salts are precipitated by the acidity ofthe chyme. So the lipids are not digested leading to “steatorrhea.”Transport of lipids: Most lipids, such as cholesterol and Triglycerides, are monpolar andtherefore very hydrophobic- molecules. To be transported in watery blood, suchmolecules are first made water-soluble by combining them with proteinsproduced by the liver and intestine. The combination thus formed is Effect of Udvarthana in Sthoulya
  45. 45. Review of literature-Obesity“Lipoprotein”. These are spherical particles that contain hundreds of molecule.In a lipoprotein, an outer shell of polar proteins plus amphipathic Phospholipidsand cholesterol molecules surrounds an inner core of hydrophobic Triglyceridesand cholesterol ester molecules. The protein in the outer shell are called“Apoprotein (apo) and are designated by letters A, B, C, D and E plus a number.Besides helping to solubilize the lipoprotein inn body fluids, each Apoproteinalso has specific functions2. There are several types of lipoproteins, each having different functions,but all essentially are transport vehicles: Lipoproteins are categorized and namedmainly according to their density, which varies with the ratio of lipids (whichhave a low density) to proteins (which have a high density). From largest andlightest to smallest and heaviest, the four major classes of lipoprotein areChylomicrons, very low-density lipoprotein (VLDL), low –density lipoprotein(LDL), and high-density lipoprotein (HDL).The following table no.12 shows different constituents of lipoproteins:Lipoprotein Protein Triglycerides Phospholipids Cholesterol 36Chylomicrons 1–2% 85 % 7% 6–7%VLDL 10 % 50 % 20 % 20 %LDL 25 % 5% 20 % 50 %HDL 40 – 45% 5 – 10 % 30 % 20 % Chylomicrons: These form in mucosal epithelial cells of the small intestine and contain exogenous (dietary) lipids. They contain small amount of fat-soluble vitamins. These enter lacteals of intestinal villi and are carried by lymph into venous blood (hence the milky appearance for plasma), and then into systemic circulation. Very low-density lipoprotein (VLDL):These forms in hepatocytes and contain endogenous Triglycerides. They carryTriglycerides, which are synthesized in hepatocytes to adipocytes. After Effect of Udvarthana in Sthoulya
  46. 46. Review of literature-Obesitydepositing some of their Triglycerides in adipose cells VLDL are converted toLDL Low-density lipoprotein (LDL): They carry about 75 % of total cholesterol in the blood and deliver it to cells through out the body for use in repair of cell membranes and synthesis of steroid hormones and bile salts. The only Apoprotein LDL contain is apo B100, which binds to LDL receptors for receptor – mediated endocytosis of LDL into a body cell. Within the cell the LDL is broken down, and the cholesterol is released to serve the cell’s needs. Once a cell has sufficient cholesterol for its activities, a negative feed back system inhibits the cells synthesis of new LDL receptors. When present in excessive numbers, LDL will also deposit cholesterol in and around smooth muscle fibers in arteries, forming fatty atherosclerotic plaques that increase the risk of coronary artery disease. For this reason, this cholesterol of LDL is called as ‘bad’ cholesterol. As some people have too few LDL receptors, their body cells cannot remove LDL from the blood; as a result their plasma LDL level is abnormally high and 37 they are more likely to develop vascular diseases. Moreover eating high fat diet increases production of VLDL inturn results in elevated LDL levels. High-density lipoprotein (HDL). It removes excess cholesterol from body cells and transports it to the liverfor the elimination. As this HDL prevents accumulation of cholesterol in theblood, a high HDL level is associated with decreased risk of coronary arterydisease and hence it is rightly termed as ‘good cholesterol’. Source and significance of blood cholesterol: There are two source of cholesterol:1. Food2. Synthesized by liver Effect of Udvarthana in Sthoulya
  47. 47. Review of literature-Obesity Food products like eggs, milk products, meat, beef, and pork. Etc. are therich source of cholesterol. Fatty foods in spite of devoid of any cholesterol willstill dramatically increase blood cholesterol level in two ways. First, a highintake of dietary fats stimulates reabsorption of cholesterol containing bile backinto the blood, so less cholesterol is lost in the feces. Second, when saturated fatsare broken down in the body hepatocytes use some of the breakdown products toproduce cholesterol.Liver and lipids: Function of liver in fat metabolism3:  A very high rate of oxidation of fatty acids to supply energy for other bodily functions  Formation of most of the lipoprotein.  Synthesis of large quantities of cholesterol and Phospholipids.  Conversion of large quantities of carbohydrates and proteins into fat 38 80% of cholesterol is synthesized in liver is converted into bile salts whichin turn are secreted into the bile. The remainder is transported in the lipoprotein,which are carried by blood to the tissue cell everywhere in the body.Exercise and lipids: Most of the energy is derived from carbohydrate during the first fewseconds or minutes of exercise, but at the time of exhaustion, as much as 60-85%of energy is derived from fats rather than carbohydrates.Assessment of blood cholesterol: In Laboratory blood cholesterol are assessed under lipid profile test. Effect of Udvarthana in Sthoulya
  48. 48. Review of literature-ObesityThe following table no.13 shows the normal limits of blood cholesterol.Sl.No. Blood Cholesterol Normal (Mg/Dl) High Risk1 Total cholesterol < 200 > 2392 LDL <130 > 1593 HDL > 40 -4 Triglycerides 10 - 190 -LDL cholesterol is calculated as follows: LDL = TC – HDL – (Triglycerides / 5) If the above mentioned normal range is exceeded then the condition istermed as Hyperlipidemia.Treatment for Hyperlipidemia:The following are the types of treatment for the Hyperlipidemia  Non-pharmacological measures, which includes low-fat diet exercise.  Pharmacological measures by using the drugs like Lovastatin (which block a key enzyme needed for the cholesterol synthesis.), colestipol (it promotes the excretion of bile in the feces.) 39The fate of lipids: Lipids, like carbohydrates, may be oxidized to produce ATP. If the bodyhas no immediate need to use lipids in this way, they are stored in adipose tissue(fat depots) through out the body and in the liver. A few lipids are used asstructural molecules or to synthesize other essential substances likePhospholipids (constituents of plasma membrane), lipoproteins (to transportcholesterol) and thromboplastins (for blood clotting).Triglycerides storage: A major function of adipose tissue is to remove Triglycerides fromChylomicrons and VLDL and to store them until they are needed for ATPproduction in other parts of the body. Effect of Udvarthana in Sthoulya
  49. 49. Review of literature-ObesityThe following table (no.14) shows the distribution of adipose tissue.SL.NO STORAGE SITE OF TRIGLYCERIDES PERCENTAGE1 Subcutaneous layer 50 %2 Around kidneys 12 %3 In omenta 10 – 15 %4 In genital area 15 %5 Between muscles 5–8%6 Behind eyes 5% Triglycerides in adipose tissue are continually broken down and re-synthesized. Thus the Triglycerides stored in adipose tissue today are not thesame molecule that were present last month because they are continuallyreleased from storage, transported in blood, and re-deposited in other adiposetissue cells.Regulation of energy release from Triglycerides: When excess quantities of carbohydrates are available in the bodycarbohydrates are used preferentially over Triglycerides for energy. There areseveral reasons for this “Fat-sparing” effect of carbohydrate. 40Lipid catabolism- lipolysis: Triglycerides stored in adipose tissue constitute 98% of all body energyreserves. They are stored more readily than is glycogen, in part becauseTriglycerides are hydrophobic and do not exert osmotic pressure on cellmembranes. Several tissues (muscle, liver and adipose tissue) routinely oxidizedfatty acids derived from Triglycerides to produce ATP; they must be split intoglycerol and fatty acids. This process is called as “lipolysis” (li-pol-i-sis) i.e.catalyzed by enzymes called lipases. Two hormones that enhance Triglyceridesbreak down into fatty acids and glycerol, are “Epinephrine” and“Norepinephrine”, which are realized when sympathetic tone increases, asoccurs during exercises. Other lipolytic hormones are cortisol, thyroid hormonesand insulin like growth factors. Insulin itself inhibits lipolysis. Effect of Udvarthana in Sthoulya
  50. 50. Review of literature-Obesity The glycerol and fatty acids that result from Liposis are catabolised viadifferent pathways. Glycerol is converted to glyceraldehyde 3-phosphate bymany cells of the body; one of the compounds also forms during the catabolismof glucose. If ATP supply in a cell is high, glyceraldehyde 3- phosphate isconverted into glucose, an ex of gluconeogenesis. Even collectively all of the manipulations to increase the blood glucoseare inadequate to provide energy supplies for prolonged fasting periods. Luckilythe body can adopt to burn more fats and proteins, which enter the Krebs cyclealong with glucose, break down products. The increased use of non-carbohydratefuel molecules (especially Triacylglycerols) to conserve glucose is called as“glucose sparing’ 3. As the body progress from the absorptive to the post-absorptive state, the brain continues to take its share of blood glucose butvirtually every other organ switches to fatty acids as its major energy sources,thus sparing glucose for the brain. During this transition phase, lipolysis beginsin adipose tissues and realized fatty acids are picked up by tissues cells andoxidized for energy. In addition the liver oxidizes fats to ketones and releasesthem into the blood for use by tissues cells. If fasting continues for longer then 4 41or 5 days the brain too begins to use large quantities of ketones bodies as well asglucose as its energy fuels.Lipid anabolism: Lipogenesis: Liver cells and adipose cells can synthesis lipids from glucose or aminoacid through Lipogenesis, which is stimulated by insulin. Lipogenesis can occurwhen a person consumes more calories than are needed to satisfy their ATPneeds. Excess dietary carbohydrates, proteins and fats all have the same fate.They are converted into Triglycerides. The glycerol and fatty acids can undergoanabolic reactions to become Triglycerides that can be stored or they can gothrough a series of anabolic reactions to produces other lipids such aslipoproteins, Phospholipids, and cholesterol. Effect of Udvarthana in Sthoulya
  51. 51. Review of literature-Obesity Etymology The word Obesity is derived from Latin term “obesus” which means:Ob → by reason ofEdo → I eatObesus → having eaten or having eaten until fatObesity → grossly fatDefinition: It is defined as “an abnormal growth of the adipose tissue due to anenlargement of fat cell size (hypertrophic) or an increase in fat cell number(hyperplastic) or a combination of both. Other definitions of obesity are as follows:  It is a state in which there is a generalized accumulation of fat in the body leading to more than 20% of the desirable weight.  Obesity is defined as BMI (Body Mass Index) above 25. 42  Obesity is a pathological condition characterized by an accumulation of body fat much in excess than that of necessary for optimal body function.  It implies an excess storage of fat. Most patients suffer from simple obesity but in certain conditions, it is anassociated feature. Even in later situation the intake of calories must beexceeding expenditure. Hormonal imbalance is often incriminated in women (ex.Post menopause or when taking contraceptive pills), but most of the weight gainin such cases is usually small and due to water retention. Effect of Udvarthana in Sthoulya
  52. 52. Review of literature-Obesity Synonyms of obesity Synonyms of obese  Plumpness  Fatty  Stoutness  Stout  Fatness  Corpulent  Over Weight  Buxom  Adiposity  Pert  Adiposis  Pulp  Liposis.  RotundPrevalence: It is most prevalent form of malnutrition in developed countries affectingadults as well as children. Obesity is a major public health problem in theindustrialized countries. It is extremely difficult to assess the size of the problemand compare the prevalence rates among the countries, as no exact figures areavailable4. The other reason for the same is lacking of standardization ofdefinition of obesity. However it has been estimated that twenty to forty percent 43of adults suffer from this disease in the developed countries like USA, UK. It isshown that fifty three percent of men aged twenty to seventy four and 1.3 to 1.5times women are obese in USA. These people spend 30-40 billion dollars everyyear on weight loss treatment. In developed countries this disease is more commonly seen in low socio-economic people where as in developing countries it is seen in higher socio-economical groups. A small study conducted recently in urban Delhi5 shown20% of men and 27.1% of women are obese (BMI > 25). Effect of Udvarthana in Sthoulya
  53. 53. Review of literature-Obesity AETIO-PATHOGENSIS The causes of obesity can be studied under three heading as it is usually done while dealing with the prevention of communicable as well as non- communicable disease. The three causative factors are referred to as “Epidemiological Triad”. They are: 1. Agent factor 2. Host factor 3. Environmental factor. In the disease Obesity, it is very difficult to separate all of these factors under different headings, as they are inter-related with each other. An attempt is made to understand these things as separate entities as much as possible. 1. Agent factor: In the disease the agent is defined as “a substance, living or non-living, or a force, tangible or intangible, the excessive presence or relative lack of which 44 4 may initiate or perpetuate a disease process” . The disease agents of obesity can be classified as follows:a) Nutrient agents: The eating habits of obese people are variable. Some eat three large meals a day, while other eats frequently five to six times a day. In both the cases excessive food intake is the cause for obesity. Not all obese patients eat more than average person, but all obviously eat more than they need. The foodstuff rich in fats are the key factor in the development of the disease. Even diets rich in simple sugars are also have definite role in the manifestation. Effect of Udvarthana in Sthoulya
  54. 54. Review of literature-Obesity It has been shown that obese patient eat more than they admit to eating, and over the years very small daily excess can lead to a large accumulation of fat. For example, 10.5 kcal excess would lead to a 10 kg weight gain over 20 years.b) Social agents: This disease is present more in effluent class of people in developing countries and in low socio-economic group in developed countries. As the poor people in developed countries can’t offer balanced diet, they are more prone to get affected. Due to increased sedentary life styles and frequent social kitty parties the people of economically rich group are affected in developing countries. 2. Host Factor: This is the intrinsic factor and is broadly classified as: I. Demographic characteristic like age, sex and ethnicity. II. Biological characteristic such as genetic factors, bio-chemical levels of blood and enzymes, physiological function of different organ 45 systems of the body. III. Social and economic characteristic like socio-economic status, education, occupation, stress etc. IV. Life style factors such as living habits, physical exercises, use of alcohol, drugs and smoking, behavioral patterns etc. ☻Age and sex: Obesity can occur at any age and generally increase with age. It has been well established that most adipose cells are formed earlier in life. Over feeding during infancy and early childhood by over enthusiastic mothers can be an important cause of obesity in adolescence and adults. It occurs in either sex and it is found that men gain weight between the ages of 29-35 while women gain most between 45-49 years of age. Women are more prone than men in gaining weight. Effect of Udvarthana in Sthoulya
  55. 55. Review of literature-Obesity☻ Genetic factors: It is very difficult to assess the role of genes in the manifestation ofobesity. But it is seen commonly in families. Re-feeding experiments inmonozygotic and dizygotic twins feed together or apart, suggest that geneticinfluences account for 70% of the difference in Body Mass Index (BMI) later inlife. Genetic factors have led to the discovery of a mutative gene, firstly in theobese (ob ob) mouse and now in humans. The ob gene was shown to beexpressed solely in both white and brown adipose tissues. The ob gene is foundon chromosome 7 and produce 16kDa protein called Leptin. In animalexperiment it has been proved that massively obese mouse; Leptin mRNA insubcutaneous adipose tissues is 80% higher than in controls. There are a numberof known genetic conditions such as Prader-willi syndrome and mutation in theLeptin gene, which produce a syndrome complex associated with obesity. The following table (no.15) shows the role of different genes inmanifestation of obesity6:GENE GENE PRODUCT MECHANISM 46Lep Leptin, a fat-derived hormone Mutation prevents Leptin from delivering satiety signal; brain receives starvationLepR Leptin receptor As abovePOMC Proopiomelanocortin, a Mutation prevents synthesis of precursor of several hormones melanocytes-stimulating and neuropeptide hormone(MSH) as satiety signalMC4R Type 4 receptor for MSH Mutation prevents reception of satiety signal from MSHPC-1 Prohormone convertase 1, a Mutation prevents synthesis of processing enzyme neuropeptide, probably MSH Whatever the role of genes may be, it is clear that environment plays animportant role, as evidenced by the fact that famine prevents obesity even in themost obesity prone individual. Effect of Udvarthana in Sthoulya

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